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1.
JAMA ; 322(3): 216-228, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31310297

RESUMO

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.


Assuntos
Delírio/prevenção & controle , Família/psicologia , Unidades de Terapia Intensiva/organização & administração , Visitas a Pacientes , Ansiedade , Brasil , Esgotamento Profissional , Cuidados Críticos/psicologia , Estudos Cross-Over , Depressão , Feminino , Educação em Saúde , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
2.
Crit Care Res Pract ; 2018: 4298583, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30123586

RESUMO

Background: Deep and respiratory muscle disorders are commonly observed in critically ill patients. Neuromuscular electrical stimulation (NMES) is an alternative to mobilize and to exercise that does not require active patient participation and can be used on bedridden patients. Objective: Evaluate the effectiveness of the NMES therapy in quadriceps versus diaphragm subjects in mechanical ventilation (MV). Methods: Sixty-seven subjects in MV were included, divided into 3 groups: (a) control group (CG, n=26), (b) stimulation of quadriceps (quadriceps group-QG, n=24), and (c) stimulation of diaphragm (diaphragm group-DG, n=17). The QG and DG patients received consecutive daily electrical stimulation sessions at specific points from the first day of randomization until ICU discharge. Respiratory and peripheral muscle strength, MV time, length of hospitalization, and functional independence score (the Functional Status Score-ICU) were recorded. Results: There were studied n=24 (QG), n=17 (DG), and n=26 (CG) patients. Peripheral muscle strength improved significantly in the QG (p=0.030). Functional independence at ICU discharge was significantly better in QG (p=0.013), and the QG presented a better Barthel Index compared to DG and CG (p=0.0049) and also presented better FSS compared to CG (p=0.001). Conclusions: Electrical stimulation of quadriceps had best outcomes for peripheral muscle strength compared with controls or electrical stimulation of diaphragm among mechanically ventilated critically ill subjects and promoted functional independence and decreased length of hospitalization.

3.
ABCS health sci ; 43(1): 61-66, maio 18, 2018. ilus
Artigo em Português | LILACS | ID: biblio-884027

RESUMO

O delirium consiste em um estado confusional agudo e de curso flutuante representando uma manifestação da disfunção cerebral que pode estar associado com diferentes manifestações clínicas. Os pacientes com delirium têm sido estudados, pois tem apresentado maior tempo de ventilação mecânica e de internação em unidade de terapia intensiva. O objetivo do estudo foi realizar uma revisão de literatura acerca da influência do delirium no tempo de ventilação mecânica, sedação e na mortalidade de pacientes internados em unidade de terapia intensiva. Foi realizada uma busca por estudos nas bases de dados PubMed e Embase, com os descritores delirium, intensive care unit and mechanical ventilation. Nos resultados foram incluídos oito artigos, um recebeu graduação A e sete receberam graduação B na escala de Oxford. Os principais resultados foram: Os pacientes com delirium apresentaram maior gravidade, maior tempo de ventilação mecânica, maior tempo de sedação e maior mortalidade. Conclui-se que o delirium parece estar associado ao maior tempo da ventilação mecânica, maior dosagem de sedação e de mortalidade nestes pacientes. (AU)


Delirium consists of an acute, fluctuating, confusional state, representing a manifestation of cerebral dysfunction that can occur with different clinical manifestations. Patients with delirium have been studied because they have had longer time of mechanical ventilation and hospitalization in the intensive care unit. The objective of the study was to perform a literature review about the influence of delirium on the time of mechanical ventilation, sedation and on the mortality of patients admitted in intensive care units. A search for studies with the keywords delirium, intensive care unit and mechanical ventilation was performed in PubMed and Embase databases. As result eight articles were included, one received level A and seven received level B on the Oxford scale. The main results were: Patients with delirium presented greater severity, longer time of mechanical ventilation, longer sedation time and higher mortality. It is concluded that delirium appears to be associated with longer mechanical ventilation, greater sedation and mortality rates in these patients. (AU)


Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Delírio/complicações , Unidades de Terapia Intensiva , Respiração Artificial
4.
BMJ Open ; 8(4): e021193, 2018 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-29654049

RESUMO

INTRODUCTION: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. METHODS AND ANALYSIS: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. ETHICS AND DISSEMINATION: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. TRIAL REGISTRATION: NCT02932358.

5.
Respir Care ; 60(11): 1527-35, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26152472

RESUMO

BACKGROUND: Failure to wean can prolong ICU stay, increase complications associated with mechanical ventilation, and increase morbidity and mortality. The spontaneous breathing trial (SBT) is one method used to assess weaning. The aim of this study was to assess proportional assist ventilation plus (PAV+) as an SBT by comparing its applicability, safety, and efficacy with T-tube and pressure support ventilation (PSV). METHODS: A randomized study was performed involving 160 adult subjects who remained on mechanical ventilation for > 24 h. Subjects were randomly assigned to the PAV+, PSV, or T-tube group. When subjects were ready to perform the SBT, subjects in the PAV+ group were ventilated in PAV+ mode (receiving support of up to 40%), the pressure support was reduced to 7 cm H2O in the PSV group, and subjects in the T-tube group were connected to one T-piece with supplemental oxygen. Subjects were observed for signs of intolerance, whereupon the trial was interrupted. When the trial succeeded, the subjects were extubated and assessed until discharge. RESULTS: The subjects were predominantly male (66.5%), and the leading cause of admission was traumatic brain injury. The groups were similar with respect to baseline characteristics, and no significant difference was observed among the groups regarding extubation success or failure. Analysis of the specificity and sensitivity revealed good sensitivity for all groups; however, the PAV+ group had higher specificity (66.6%) and higher sensitivity (97.6%), with prediction of ∼ 92.1% of the success and failure events. CONCLUSIONS: No significant differences in the groups was observed regarding the rate of extubation failure, duration of mechanical ventilation, and ICU and hospital stay, indicating that PAV+ is an alternative for use as an SBT.


Assuntos
Extubação , Suporte Ventilatório Interativo , Respiração , Desmame do Respirador/métodos , Adulto , Feminino , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal , Masculino , Estudos Prospectivos , Testes de Função Respiratória , Sensibilidade e Especificidade
6.
J Crit Care ; 30(3): 655.e1-6, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25622762

RESUMO

PURPOSE: To assess the effects of passive orthostatism on various clinicophysiologic parameters of adult intensive care unit (ICU) patients, by daily placement on a tilt table. MATERIALS AND METHODS: This prospective cohort study was performed in a general ICU. Twenty-three patients 18 years or older, intubated or tracheostomized, without sedation and under weaning from mechanical ventilation, were analyzed. All variables were evaluated at tilting of 30°, 45°, 60°, 75°, and 90°. RESULTS: Glasgow Coma Scale increased during tilt in the first and second day, as well as Richmond Agitation-Sedation Scale. No significant differences were detected in the physiological parameters; however, there was a nonsignificant decrease on the mean arterial pressure at angles of 75° and 90°. The maximum inspiratory pressure significantly increased at 60° compared with 30° on day 1 of the intervention. No significant differences were observed for maximum expiratory pressure, rapid shallow breathing index, and the tidal volume. CONCLUSION: A protocol with daily use of a tilt table for ICU patients is safe and improves the level of consciousness and inspiratory maximum pressure, without causing deleterious acute physiological effects.


Assuntos
Estado de Consciência , Cuidados Críticos , Deambulação Precoce , Posicionamento do Paciente/métodos , Adulto , Idoso , Estudos de Coortes , Feminino , Escala de Coma de Glasgow , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial , Volume de Ventilação Pulmonar
7.
Rev Bras Ter Intensiva ; 26(3): 215-39, 2014 Jul-Sep.
Artigo em Inglês, Português | MEDLINE | ID: mdl-25295817

RESUMO

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.


Assuntos
Cuidados Críticos/métodos , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Brasil , Cuidados Críticos/normas , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva/normas , Qualidade da Assistência à Saúde
8.
Rev Bras Ter Intensiva ; 26(3): 299-304, 2014 Jul-Sep.
Artigo em Inglês, Português | MEDLINE | ID: mdl-25295825

RESUMO

OBJECTIVE: To assess the opinions and practices of intensive care professionals with regard to diarrhea in critically ill patients. METHODS: A multicenter cross-sectional study was conducted among health care professionals working at three adult intensive care units.Participants responded individually to a self-administered questionnaire about their length of work experience in intensive care; the definition,characterization, and causes of diarrhea;types of records in the patient's medical record; and training received. RESULTS: A total of 78 professionals participated in this study, of whom 59.0% were nurse technicians, 25.7%were nurses, and 15.3% were physicians;77.0% of them had worked in intensive care for over 1 year. Only 37.2% had received training on this topic. Half of the interviewees defined diarrhea as "liquid and/or pasty stools" regardless of frequency, while the other 50.0% defined diarrhea based on the increased number of daily bowel movements. The majority of them mentioned diet as the main cause of diarrhea, followed by "use of medications" (p<0.001). Distinct nutritional practices were observed among the analyzed professionals regarding episodes of diarrhea, such as discontinuing, maintaining, or reducing the volume of enteral nutrition; physicians reported that they do not routinely communicate the problem to other professionals (for example, to a nutritionist) and do not routinely record and quantify diarrhea events in patients' medical records. CONCLUSION: Different opinions and practices were observed in intensive care professionals with regard to diarrhea.


Assuntos
Diarreia/terapia , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva , Adolescente , Adulto , Estado Terminal , Estudos Transversais , Nutrição Enteral/métodos , Feminino , Humanos , Masculino , Inquéritos e Questionários , Adulto Jovem
9.
Rev. bras. ter. intensiva ; 26(3): 299-304, Jul-Sep/2014. tab, graf
Artigo em Português | LILACS | ID: lil-723276

RESUMO

Objetivo: Avaliar opiniões e condutas de profissionais atuantes em unidades de terapia intensiva relacionadas à diarreia do paciente grave. Métodos: Estudo transversal, multicêntrico realizado com profissionais de saúde de três unidades de terapia intensiva de adultos. Os participantes responderam individualmente a um questionário autoaplicável sobre tempo de atuação profissional em terapia intensiva; definição, caracterização e causas da diarreia; formas de registro no prontuário; e treinamentos recebidos. Resultados: Participaram 78 profissionais, sendo 59,0% técnicos em enfermagem, 25,7% enfermeiros e 15,3% médicos; 77,0% trabalham em terapia intensiva há mais de 1 ano. Apenas 37,2% tinham realizado previamente algum treinamento relacionado. Metade dos entrevistados caracterizou diarreia como "evacuações líquidas e/ou pastosas" independentemente da frequência, enquanto os outros 50,0% caracterizaram pelo aumento do número de episódios diários de evacuações. A maioria referiu a dieta como principal fator causal da diarreia, seguida de "uso de medicamentos" (p<0,001). Foram detectadas condutas nutricionais distintas entre os profissionais pesquisados frente a um episódio de diarreia, no tocante a suspender, manter ou reduzir a dieta; os médicos referiram não ter o hábito de comunicar a outro profissional (por exemplo, o nutricionista), assim como não referiram o hábito de registrar e quantificar os eventos de diarreia no prontuário. Conclusão: Detectou-se pluralidade de opiniões e atitudes dos profissionais de terapia intensiva relacionadas à diarreia. .


Objective: To assess the opinions and practices of intensive care professionals with regard to diarrhea in critically ill patients. Methods: A multicenter cross-sectional study was conducted among health care professionals working at three adult intensive care units. Participants responded individually to a self-administered questionnaire about their length of work experience in intensive care; the definition, characterization, and causes of diarrhea; types of records in the patient's medical record; and training received. Results: A total of 78 professionals participated in this study, of whom 59.0% were nurse technicians, 25.7% were nurses, and 15.3% were physicians; 77.0% of them had worked in intensive care for over 1 year. Only 37.2% had received training on this topic. Half of the interviewees defined diarrhea as "liquid and/or pasty stools" regardless of frequency, while the other 50.0% defined diarrhea based on the increased number of daily bowel movements. The majority of them mentioned diet as the main cause of diarrhea, followed by "use of medications" (p<0.001). Distinct nutritional practices were observed among the analyzed professionals regarding episodes of diarrhea, such as discontinuing, maintaining, or reducing the volume of enteral nutrition; physicians reported that they do not routinely communicate the problem to other professionals (for example, to a nutritionist) and do not routinely record and quantify diarrhea events in patients' medical records. Conclusion: Different opinions and practices were observed in intensive care professionals with regard to diarrhea. .


Assuntos
Adolescente , Adulto , Feminino , Humanos , Masculino , Adulto Jovem , Diarreia/terapia , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva , Estado Terminal , Estudos Transversais , Nutrição Enteral/métodos , Inquéritos e Questionários
10.
Barbas, Carmen Sílvia Valente; Ísola, Alexandre Marini; Farias, Augusto Manoel de Carvalho; Cavalcanti, Alexandre Biasi; Gama, Ana Maria Casati; Duarte, Antonio Carlos Magalhães; Vianna, Arthur; Serpa Neto, Ary; Bravim, Bruno de Arruda; Pinheiro, Bruno do Valle; Mazza, Bruno Franco; Carvalho, Carlos Roberto Ribeiro de; Toufen Júnior, Carlos; David, Cid Marcos Nascimento; Taniguchi, Corine; Mazza, Débora Dutra da Silveira; Dragosavac, Desanka; Toledo, Diogo Oliveira; Costa, Eduardo Leite; Caser, Eliana Bernadete; Silva, Eliezer; Amorim, Fabio Ferreira; Saddy, Felipe; Galas, Filomena Regina Barbosa Gomes; Silva, Gisele Sampaio; Matos, Gustavo Faissol Janot de; Emmerich, João Claudio; Valiatti, Jorge Luis dos Santos; Teles, José Mario Meira; Victorino, Josué Almeida; Ferreira, Juliana Carvalho; Prodomo, Luciana Passuello do Vale; Hajjar, Ludhmila Abrahão; Martins, Luiz Claudio; Malbouisson, Luis Marcelo Sá; Vargas, Mara Ambrosina de Oliveira; Reis, Marco Antonio Soares; Amato, Marcelo Brito Passos; Holanda, Marcelo Alcântara; Park, Marcelo; Jacomelli, Marcia; Tavares, Marcos; Damasceno, Marta Cristina Paulette; Assunção, Murillo Santucci César; Damasceno, Moyzes Pinto Coelho Duarte; Youssef, Nazah Cherif Mohamed; Teixeira, Paulo José Zimmermann; Caruso, Pedro; Duarte, Péricles Almeida Delfino; Messeder, Octavio; Eid, Raquel Caserta; Rodrigues, Ricardo Goulart; Jesus, Rodrigo Francisco de; Kairalla, Ronaldo Adib; Justino, Sandra; Nemer, Sergio Nogueira; Romero, Simone Barbosa; Amado, Verônica Moreira.
Rev. bras. ter. intensiva ; 26(3): 215-239, Jul-Sep/2014. tab, graf
Artigo em Português | LILACS | ID: lil-723283

RESUMO

O suporte ventilatório artificial invasivo e não invasivo ao paciente grave tem evoluído e inúmeras evidências têm surgido, podendo ter impacto na melhora da sobrevida e da qualidade do atendimento oferecido nas unidades de terapia intensiva no Brasil. Isto posto, a Associação de Medicina Intensiva Brasileira (AMIB) e a Sociedade Brasileira de Pneumologia e Tisiologia (SBPT) - representadas por seu Comitê de Ventilação Mecânica e sua Comissão de Terapia Intensiva, respectivamente, decidiram revisar a literatura e preparar recomendações sobre ventilação mecânica, objetivando oferecer aos associados um documento orientador das melhores práticas da ventilação mecânica na beira do leito, com base nas evidências existentes, sobre os 29 subtemas selecionados como mais relevantes no assunto. O projeto envolveu etapas que visaram distribuir os subtemas relevantes ao assunto entre experts indicados por ambas as sociedades, que tivessem publicações recentes no assunto e/ou atividades relevantes em ensino e pesquisa no Brasil, na área de ventilação mecânica. Esses profissionais, divididos por subtemas em duplas, responsabilizaram-se por fazer uma extensa revisão da literatura mundial. Reuniram-se todos no Fórum de Ventilação Mecânica, na sede da AMIB, na cidade de São Paulo (SP), em 3 e 4 de agosto de 2013, para finalização conjunta do texto de cada subtema e apresentação, apreciação, discussão e aprovação em plenária pelos 58 participantes, permitindo a elaboração de um documento final.


Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.


Assuntos
Humanos , Cuidados Críticos/métodos , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Brasil , Cuidados Críticos/normas , Estado Terminal/terapia , Unidades de Terapia Intensiva/normas , Qualidade da Assistência à Saúde
11.
Crit Care Res Pract ; 2014: 546349, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24982804

RESUMO

Background. We compare the incidence of delirium before and after extubation and identify the risk factors and possible predictors for the occurrence of delirium in this group of patients. Methods. Patients weaned from mechanical ventilation (MV) and extubated were included. The assessment of delirium was conducted using the confusion assessment method for the ICU and completed twice per day until discharge from the intensive care unit. Results. Sixty-four patients were included in the study, 53.1% of whom presented with delirium. The risk factors of delirium were age (P = 0.01), SOFA score (P = 0.03), APACHE score (P = 0.01), and a neurological cause of admission (P = 0.01). The majority of the patients began with delirium before or on the day of extubation. Hypoactive delirium was the most common form. Conclusion. Acute (traumatic or medical) neurological injuries were important risk factors in the development of delirium. During the weaning process, delirium developed predominantly before or on the same day of extubation and was generally hypoactive (more difficult to detect). Therefore, while planning early prevention strategies, attention must be focused on neurological patients who are receiving MV and possibly even on patients who are still under sedation.

12.
Rev Bras Ter Intensiva ; 26(2): 122-9, 2014 Apr-Jun.
Artigo em Inglês, Português | MEDLINE | ID: mdl-25028945

RESUMO

OBJECTIVE: To investigate the relationship between sedation and the memories reported by patients subjected to mechanical ventilation following discharge from the intensive care unit. METHODS: This prospective, observational, cohort study was conducted with individuals subjected to mechanical ventilation who remained in the intensive care unit for more than 24 hours. Clinical statistics and sedation records were extracted from the participants' clinical records; the data relative to the participants' memories were collected using a specific validated instrument. Assessment was performed three months after discharge from the intensive care unit. RESULTS: A total of 128 individuals were assessed, most of whom (84.4%) reported recollections from their stay in the intensive care unit as predominantly a combination of real and illusory events. The participants subjected to sedation (67.2%) at deep levels (Richmond Agitation-Sedation Scale [RASS] -4 and -5) for more than two days and those with psychomotor agitation (33.6%) exhibited greater susceptibility to occurrence of illusory memories (p>0.001). CONCLUSION: The probability of the occurrence of illusory memories was greater among the participants who were subjected to deep sedation. Sedation seems to be an additional factor that contributed to the occurrence of illusory memories in severely ill individuals subjected to mechanical ventilation.


Assuntos
Hipnóticos e Sedativos/administração & dosagem , Unidades de Terapia Intensiva , Memória/fisiologia , Respiração Artificial/métodos , Adolescente , Adulto , Idoso , Estudos de Coortes , Sedação Profunda/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Agitação Psicomotora/epidemiologia , Respiração Artificial/psicologia , Fatores de Tempo , Adulto Jovem
13.
Rev Bras Ter Intensiva ; 26(2): 89-121, 2014 Apr-Jun.
Artigo em Inglês, Português | MEDLINE | ID: mdl-25028944

RESUMO

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.


Assuntos
Estado Terminal/terapia , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Brasil , Cuidados Críticos/métodos , Humanos , Unidades de Terapia Intensiva/normas , Qualidade da Assistência à Saúde
14.
Barbas, Carmen Sílvia Valente; Ísola, Alexandre Marini; Farias, Augusto Manoel de Carvalho; Cavalcanti, Alexandre Biasi; Gama, Ana Maria Casati; Duarte, Antonio Carlos Magalhães; Vianna, Arthur; Serpa Neto, Ary; Bravim, Bruno de Arruda; Pinheiro, Bruno do Valle; Mazza, Bruno Franco; Carvalho, Carlos Roberto Ribeiro de; Toufen Júnior, Carlos; David, Cid Marcos Nascimento; Taniguchi, Corine; Mazza, Débora Dutra da Silveira; Dragosavac, Desanka; Toledo, Diogo Oliveira; Costa, Eduardo Leite; Caser, Eliana Bernardete; Silva, Eliezer; Amorim, Fabio Ferreira; Saddy, Felipe; Galas, Filomena Regina Barbosa Gomes; Silva, Gisele Sampaio; Matos, Gustavo Faissol Janot de; Emmerich, João Claudio; Valiatti, Jorge Luis dos Santos; Teles, José Mario Meira; Victorino, Josué Almeida; Ferreira, Juliana Carvalho; Prodomo, Luciana Passuello do Vale; Hajjar, Ludhmila Abrahão; Martins, Luiz Cláudio; Malbouisson, Luiz Marcelo Sá; Vargas, Mara Ambrosina de Oliveira; Reis, Marco Antonio Soares; Amato, Marcelo Brito Passos; Holanda, Marcelo Alcântara; Park, Marcelo; Jacomelli, Marcia; Tavares, Marcos; Damasceno, Marta Cristina Paulette; Assunção, Murillo Santucci César; Damasceno, Moyzes Pinto Coelho Duarte; Youssef, Nazah Cherif Mohamad; Teixeira, Paulo José Zimmermann; Caruso, Pedro; Duarte, Péricles Almeida Delfino; Messeder, Octavio; Eid, Raquel Caserta; Rodrigues, Ricardo Goulart; Jesus, Rodrigo Francisco de; Kairalla, Ronaldo Adib; Justino, Sandra; Nemer, Sérgio Nogueira; Romero, Simone Barbosa; Amado, Verônica Moreira.
Rev. bras. ter. intensiva ; 26(2): 89-121, Apr-Jun/2014. tab, graf
Artigo em Português | LILACS | ID: lil-714821

RESUMO

O suporte ventilatório artificial invasivo e não invasivo ao paciente crítico tem evoluído e inúmeras evidências têm surgido, podendo ter impacto na melhora da sobrevida e da qualidade do atendimento oferecido nas unidades de terapia intensiva no Brasil. Isto posto, a Associação de Medicina Intensiva Brasileira (AMIB) e a Sociedade Brasileira de Pneumonia e Tisiologia (SBPT) - representadas pelo seus Comitê de Ventilação Mecânica e Comissão de Terapia Intensiva, respectivamente, decidiram revisar a literatura e preparar recomendações sobre ventilação mecânica objetivando oferecer aos associados um documento orientador das melhores práticas da ventilação mecânica na beira do leito, baseado nas evidencias existentes, sobre os 29 subtemas selecionados como mais relevantes no assunto. O projeto envolveu etapas visando distribuir os subtemas relevantes ao assunto entre experts indicados por ambas as sociedades que tivessem publicações recentes no assunto e/ou atividades relevantes em ensino e pesquisa no Brasil na área de ventilação mecânica. Esses profissionais, divididos por subtemas em duplas, responsabilizaram-se por fazer revisão extensa da literatura mundial sobre cada subtema. Reuniram-se todos no Forum de Ventilação Mecânica na sede da AMIB em São Paulo, em 03 e 04 de agosto de 2013 para finalização conjunta do texto de cada subtema e apresentação, apreciação, discussão e aprovação em plenária pelos 58 participantes, permitindo a elaboração de um documento final.


Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.


Assuntos
Humanos , Estado Terminal/terapia , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Brasil , Cuidados Críticos/métodos , Unidades de Terapia Intensiva/normas , Qualidade da Assistência à Saúde
15.
Rev. bras. ter. intensiva ; 26(2): 122-129, Apr-Jun/2014. tab, graf
Artigo em Português | LILACS | ID: lil-714830

RESUMO

Objetivo: Investigar a relação entre sedação e as memórias relatadas por pacientes submetidos à ventilação mecânica após a alta da unidade de terapia intensiva. Métodos: Estudo de coorte prospectivo, observacional, realizado com pacientes submetidos à ventilação mecânica e que permaneceram por mais de 24 horas na unidade de terapia intensiva. Dados clínicos e de sedação foram pesquisados em prontuários, e os dados referentes às memórias do paciente foram coletados por meio de um instrumento validado para esse fim. As avaliações foram realizadas 3 meses após a alta da unidade de terapia intensiva. Resultados: Dos 128 pacientes avaliados, a maioria (84,4%) relatou lembranças do período de internação na unidade de terapia intensiva, prevalecendo uma combinação de eventos reais e ilusórios. Pacientes que permaneceram sedados (67,2%), com sedação profunda (RASS -4 e -5) durante um período maior do que 2 dias e que apresentaram agitação psicomotora (33,6%) foram mais suscetíveis a apresentarem memórias ilusórias (p>0,001). Conclusão: A probabilidade de os pacientes apresentarem memórias de ilusão foi maior naqueles com sedação profunda. A sedação, portanto, parece ser um fator adicional que contribuiu para o desenvolvimento de memórias ilusórias em pacientes gravemente enfermos e submetidos à ventilação mecânica. .


Objective: To investigate the relationship between sedation and the memories reported by patients subjected to mechanical ventilation following discharge from the intensive care unit. Methods: This prospective, observational, cohort study was conducted with individuals subjected to mechanical ventilation who remained in the intensive care unit for more than 24 hours. Clinical statistics and sedation records were extracted from the participants' clinical records; the data relative to the participants' memories were collected using a specific validated instrument. Assessment was performed three months after discharge from the intensive care unit. Results: A total of 128 individuals were assessed, most of whom (84.4%) reported recollections from their stay in the intensive care unit as predominantly a combination of real and illusory events. The participants subjected to sedation (67.2%) at deep levels (Richmond Agitation-Sedation Scale [RASS] -4 and -5) for more than two days and those with psychomotor agitation (33.6%) exhibited greater susceptibility to occurrence of illusory memories (p>0.001). Conclusion: The probability of the occurrence of illusory memories was greater among the participants who were subjected to deep sedation. Sedation seems to be an additional factor that contributed to the occurrence of illusory memories in severely ill individuals subjected to mechanical ventilation. .


Assuntos
Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Hipnóticos e Sedativos/administração & dosagem , Unidades de Terapia Intensiva , Memória/fisiologia , Respiração Artificial/métodos , Estudos de Coortes , Sedação Profunda/métodos , Seguimentos , Estudos Prospectivos , Agitação Psicomotora/epidemiologia , Respiração Artificial/psicologia , Fatores de Tempo
16.
Einstein (Säo Paulo) ; 10(3): 306-311, jul.-set. 2012. ilus, tab
Artigo em Português | LILACS | ID: lil-654340

RESUMO

OBJETIVO: Analisar as alterações histológicas pulmonares de quatro casos fatais de influenza pandêmica H1N1, correlacionando-os a características clínico-epidemiológicas. MÉTODOS: Estudo retrospectivo e descritivo de dados de prontuários de quatro pacientes que faleceram por influenza H1N1 na Unidade de Terapia Intensiva de um hospital universitário, em 2009. Os pacientes haviam sido submetidos a aspirado de nasofaringe e as amostras foram analisadas pelo método de reação em cadeia da polimerase em tempo real. Biópsia pulmonar foi realizada no dia do óbito; um escore de intensidade das alterações histopatológica foi aplicado. RESULTADOS: Três pacientes apresentaram reação em cadeia da polimerase em tempo real com resultado positivo (embora todos tivessem diagnóstico de influenza H1N1). As principais alterações histológicas identificadas foram: dano alveolar difuso exsudativo, com atelectasia de alvéolos; graus variáveis de hemorragia e edema alveolar; necrose e descamação do epitélio respiratório de vários bronquíolos; e formação de trombos. Uma das pacientes (gestante) apresentou, à histopatologia, achado de inclusão citomegálica. CONCLUSÃO: Os achados histopatológicos pulmonares em pacientes com influenza H1N1 fatal revelaram dano alveolar grave, com hemorragia alveolar e bronquiolite. Foi descrita uma coinfecção com citomegalovírus em paciente gestante.


OBJECTIVE: To analyze the histopathological lung findings of four fatal cases of the 2009 H1N1 influenza pandemic and their correlation with clinical and epidemiological characteristics. METHODS: Descriptive data from medical records of four patients who died in the Intensive Care Unit of a university hospital in 2009. Nasopharyngeal aspirate specimens were collected from the patients and were analyzed by real-time polymerase chain reaction. Lung biopsy was performed post mortem; a score of intensity for pathological changes was applied. RESULTS: Three patients had positive real-time polymerase chain reaction (although all of them had a clinical diagnose of influenza H1N1). The main histopathological changes were: exudative diffuse alveolar damage with atelectasis; varying degrees of alveolar hemorrhage and edema, necrosis and sloughing of the respiratory epithelium in several bronchioli; and thrombus formation. One of the patients (the pregnant one) presented histopathological findings of cytomegalic inclusion. CONCLUSION: The pulmonary histopathological findings in patients with fatal 2009 H1N1 influenza pandemic disclosed intense alveolar damage and hemorrhage and severe bronchiolitis. A co-infection with cytomegalovirus was described in the pregnant patient.


Assuntos
Surtos de Doenças , Vírus da Influenza A Subtipo H1N1 , Unidades de Terapia Intensiva
17.
Rev Bras Enferm ; 65(2): 285-90, 2012 Mar-Apr.
Artigo em Português | MEDLINE | ID: mdl-22911411

RESUMO

The objective of this study was to evaluate whether the sound pressure levels are decreased in the ICU after an educational intervention with the multidisciplinary team. Noise levels were measured inside the ICU (using a decibelimeter installed near the bedside of a patient) for seven days, and repeated the procedure after an educational intervention, which consisted of lectures, posters and dramatizations, among others. There was a large reduction in noise level between the pre and postintervention period, at all times evaluated. The main sources of noise in the ICU were the own team. The noise levels were higher than recommended. The study showed that with an educational intervention with the ICU staff and their awareness of the mechanisms and effects, it is possible to have reduced levels of noise and consequent estresse environment.


Assuntos
Pessoal de Saúde/educação , Unidades de Terapia Intensiva/normas , Ruído/prevenção & controle , Humanos
18.
Rev. Soc. Bras. Clín. Méd ; 10(4)jul.-ago. 2012.
Artigo em Português | LILACS | ID: lil-646065

RESUMO

JUSTIFICATIVA E OBJETIVOS: A epidemiologia e uso de estratégias ventilatórias variam amplamente entre pacientes submetidos à ventilação mecânica (VM). O objetivo deste estudo foi avaliar o perfil dos pacientes submetidos à VM em diferentes instituições, bem como as estratégias ventilatórias e complicações.MÉTODO: Estudo de coorte prospectivo de pacientes submetidos à VM por período maior de 24h em cinco unidades de terapia intensiva (UTI) de três cidades da região Oeste do estado do Paraná. Foram analisados dados clínico-demográficos,complicações durante o período de VM e desfechos clínicos. As estratégias ventilatórias, de desmame e tratamento clínico geral ficaram a critério de cada UTI. RESULTADOS: Foram avaliados 242 pacientes (idade mediana de 49 anos; 65,7% do sexo masculino), que ficaram em VM por um período mediano de 8 dias. A etiologia mais frequente foi trauma e clínico/cardiológico. O modo ventilatório mais utilizado foi assistido-controlado ciclado a volume. Traqueostomia foi realizada em 36,8%, no 8º dia de VM. Pneumonia associada à VM ocorreu em 35,1% dos pacientes. A mortalidade na UTI foi de 45,0%, sendo de 47,5% nos pacientes com síndrome do desconforto respiratório agudo. Houve grande variabilidade na utilização de estratégias e nos resultados entre as instituições e de acordo com a etiologia. CONCLUSÃO: As características clínicas e utilização de estratégias ventilatórias variam amplamente entre os pacientes com insuficiência respiratória e VM. O conhecimento da epidemiologia e das condutas clínicas utilizadas pode contribuir para redução de complicações e melhor evolução entre estes pacientes.


BACKGROUND AND OBJECTIVES: Epidemiology and ventilatory strategies vary widely among patients undergoin gmechanical ventilation (MV). The objective of this study was to evaluate the profile of patients submitted to MV in different institutions, as well as ventilation strategies and complications. METHOD: Prospective cohort study of patients undergoing MV for longer than 24 hours in five intensive care units (ICU) of three cities in Paraná state, southern Brazil. We analyzed clinical and demographic data, complications during mechanical ventilation and clinical outcomes. Ventilatory strategies, weaning and clinical management were kept according of each ICU. RESULTS: It was evaluated 242 patients (median age 49 years; 65.7% male) who remained on MV for a median of 8 days.The most frequent etiologies were trauma and clinical/cardiology. Most used ventilatory mode was assisted controlled cycled volume. Tracheostomy was performed in 36.8%, at 8th day of MV. Ventilator-associated pneumonia occurred in 35.1% of patients.The ICU mortality was 45.0% (being 47.5% in patients with acute respiratory distress syndrome. There was great variability in the use of strategies and outcomes between institutions as well as according to the etiology. CONCLUSION: Clinical features and use of ventilatory strategies varies widely among patients with respiratory failure and MV. Knowledge of the epidemiology and clinical procedures used may contribute to reducing complications and better outcomes among these patients.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Insuficiência Respiratória/complicações , Insuficiência Respiratória/epidemiologia , Avaliação de Resultados (Cuidados de Saúde) , Pneumonia/complicações , Pneumonia/epidemiologia , Respiração Artificial/métodos , Traqueostomia/métodos
19.
Rev. bras. enferm ; 65(2): 285-290, mar.-abr. 2012. graf, tab
Artigo em Português | BDENF - Enfermagem | ID: bde-26039

RESUMO

O objetivo deste estudo foi avaliar se os níveis de pressão sonora dentro da UTI são diminuídos após intervenção educativa com a equipe multiprofissional. Foram mensurados os níveis de ruído no interior da UTI (através de um decibelímetro instalado próximo à cabeceira de um paciente) durante sete dias, sendo repetido o procedimento após uma intervenção educativa, a qual consistiu de palestras, cartazes e dramatizações, entre outros. Houve grande redução do nível de ruído entre o período pré e pós-intervenção, em todos os horários avaliados. As principais fontes de ruídos dentro da UTI foram da própria equipe. Os níveis de ruído encontrados estiveram acima do recomendado. O estudo mostrou que, com uma intervenção educacional junto à equipe da UTI e sua conscientização sobre os mecanismos e efeitos, é possível haver redução dos níveis de ruído e consequente eestressee do ambiente.(AU)


The objective of this study was to evaluate whether the sound pressure levels are decreased in the ICU after an educational intervention with the multidisciplinary team. Noise levels were measured inside the ICU (using a decibelimeter installed near the bedside of a patient) for seven days, and repeated the procedure after an educational intervention, which consisted of lectures, posters and dramatizations, among others. There was a large reduction in noise level between the pre and postintervention period, at all times evaluated. The main sources of noise in the ICU were the own team. The noise levels were higher than recommended. The study showed that with an educational intervention with the ICU staff and their awareness of the mechanisms and effects, it is possible to have reduced levels of noise and consequent estresse environment.(AU)


El objetivo de este estudio fue evaluar si los niveles de presión sonora se redujeron en la UCI después de una intervención educativa con el equipo multidisciplinario. Se midieron los niveles de ruido en la UCI (utilizando un decibelímetro instalado cerca de la cabecera de un paciente) durante siete días, y se repite el procedimiento después de una intervención educativa con el equipo, que consistió en conferencias, carteles y dramatizaciones, entre otros. Hubo una gran reducción en el nivel de ruido entre el período pre y post-intervención, en todos los tiempos evaluados. Las principales fuentes de ruido en la UCI fueron del proprio equipo. Los niveles de ruidos encontrados eran más altos que los recomendados. Este estudio mostró que con una intervención educativa y de sensibilización acerca de los mecanismos y los efectos del ruido con el personal de la UCI, es posible lograr la reducción de los niveles de ruido y el estrés ambiental consecuente.(AU)


Assuntos
Humanos , Pessoal de Saúde/educação , Unidades de Terapia Intensiva/normas , Ruído/prevenção & controle
20.
Rev. bras. enferm ; 65(2): 285-290, mar.-abr. 2012. graf, tab
Artigo em Português | LILACS | ID: lil-646395

RESUMO

O objetivo deste estudo foi avaliar se os níveis de pressão sonora dentro da UTI são diminuídos após intervenção educativa com a equipe multiprofissional. Foram mensurados os níveis de ruído no interior da UTI (através de um decibelímetro instalado próximo à cabeceira de um paciente) durante sete dias, sendo repetido o procedimento após uma intervenção educativa, a qual consistiu de palestras, cartazes e dramatizações, entre outros. Houve grande redução do nível de ruído entre o período pré e pós-intervenção, em todos os horários avaliados. As principais fontes de ruídos dentro da UTI foram da própria equipe. Os níveis de ruído encontrados estiveram acima do recomendado. O estudo mostrou que, com uma intervenção educacional junto à equipe da UTI e sua conscientização sobre os mecanismos e efeitos, é possível haver redução dos níveis de ruído e consequente eestressee do ambiente.


The objective of this study was to evaluate whether the sound pressure levels are decreased in the ICU after an educational intervention with the multidisciplinary team. Noise levels were measured inside the ICU (using a decibelimeter installed near the bedside of a patient) for seven days, and repeated the procedure after an educational intervention, which consisted of lectures, posters and dramatizations, among others. There was a large reduction in noise level between the pre and postintervention period, at all times evaluated. The main sources of noise in the ICU were the own team. The noise levels were higher than recommended. The study showed that with an educational intervention with the ICU staff and their awareness of the mechanisms and effects, it is possible to have reduced levels of noise and consequent estresse environment.


El objetivo de este estudio fue evaluar si los niveles de presión sonora se redujeron en la UCI después de una intervención educativa con el equipo multidisciplinario. Se midieron los niveles de ruido en la UCI (utilizando un decibelímetro instalado cerca de la cabecera de un paciente) durante siete días, y se repite el procedimiento después de una intervención educativa con el equipo, que consistió en conferencias, carteles y dramatizaciones, entre otros. Hubo una gran reducción en el nivel de ruido entre el período pre y post-intervención, en todos los tiempos evaluados. Las principales fuentes de ruido en la UCI fueron del proprio equipo. Los niveles de ruidos encontrados eran más altos que los recomendados. Este estudio mostró que con una intervención educativa y de sensibilización acerca de los mecanismos y los efectos del ruido con el personal de la UCI, es posible lograr la reducción de los niveles de ruido y el estrés ambiental consecuente.


Assuntos
Humanos , Pessoal de Saúde/educação , Unidades de Terapia Intensiva/normas , Ruído/prevenção & controle
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